Tuesday, 26 October 2010

It began as an out of the ordinary referral, and then just got stranger and stranger...

The call came from the Criminal Justice Liaison Nurse. He had been asked to assess Stella, a 62 year old woman in Charwood Police Station, who was under arrest on suspicion of attempted murder.

“I’m at the station now,” he said. “I’ve just seen her. She can’t seem to stay on topic, and gives long rambling answers to even the simplest questions. I asked her a question about a next of kin, and she replied ‘I usually I do everything in 12’s and 24’s because I used to be a Playboy Bunny’. She just isn’t making any sense. I don’t think she’s fit to be interviewed. She needs an assessment under the Mental Health Act.”

And what had actually happened to result in Stella’s arrest?

“She called for an ambulance late last night. When the crew arrived they found her husband with a knife protruding from his ribs. The police were called and arrested her. Her husband’s in Charwood Hospital now being patched up.”

I arranged for our local psychiatrist and a Sec.12 approved doctor to attend with me. I checked our local records, but Stella had no psychiatric history, so when we arrived at the police station we had very little information to go on. The only thing I’d been able to find out was that her husband had spent a brief time in Charwood psychiatric unit over ten years ago being treated for “alcoholic hallucinosis”. This was another term for the “DT’s” – vivid and frightening hallucinations resulting from acute alcohol withdrawal. He obviously had a history of alcohol abuse.

The custody officer gave us more information about the circumstances of Stella’s arrest. The police had attended; finding a man with a knife sticking out of him and with only one other person in the house, his wife, Stella, they reached the likely conclusion that the uninjured person had inflicted the wound on the injured person, and had therefore arrested Stella. The police do have suspicious minds.

“The reports we’ve had from the hospital so far suggest that the husband is mentally ill himself. He says there are people hiding under his bed who want to kill him. He says he stuck the knife into himself. They think he’s psychotic. They’re arranging for him to have a mental health assessment as well,” the custody officer told us. “And we’ve had reports from the officers investigating the incident that seem to indicate Stella’s known in the area for being ‘different’ to say the least.”

We had Stella brought to the doctor’s room in the custody area, so that she could be interviewed “in a suitable manner”. In fact, the doctor’s room is far from ideal: it’s a poky little room, always too hot, with a desk, two chairs, a treatment couch, a fridge for forensic samples, and a toilet cubicle. It meant that two of us had to perch on the couch while interviewing her. However, it’s somewhat better that interviewing someone in a cell.

Stella was a slight woman, conservatively and appropriately dressed, with evidence of good self care. She seemed intelligent and articulate. She maintained good eye contact with us throughout, and cooperated fully with the interview.

I began by explaining to her why we were being asked to interview her, then we asked her to tell us what had happened the previous evening. She proceeded to tell us at great length everything she had done that evening, giving us a minute by minute account of the entire evening. We were quite keen for her to tell us how her husband had came to have a knife in his abdomen, but she would not be diverted from answering the question in as much detail as possible. She had gone out on her bike (she does not drive) to the supermarket for some items, and had then gone to visit a friend. She give us more details than we wanted of what they had said to each other and how many cups of tea she had drunk. She had eventually returned to the house at 2200 hrs. She said she felt there was something wrong with her husband, as he seemed to be staring at something in the corner of the room and was mumbling as if talking to someone. In an effort to snap him out of it, she suggested they have a cup of tea, and he had then abruptly got up and gone into the kitchen. After a while, as she had not heard the kettle, she went into the kitchen herself, but he was nowhere to be seen. She saw blood on the floor near the sink and followed a trail of drips until she eventually found him collapsed in the toilet with a knife sticking out of his stomach. She had then rung for the ambulance.

Throughout our interview, Stella appeared lucid and ocoherent. There was no evidence of being under the influence of alcohol or drugs. She denied any use of illegal drugs, currently or historically. She was fully orientated in time and place. There was no evidence of dementia, or emotional lability or abnormal mood. In fact, there was no evidence at all of any mental disorder. The only thing of note was that she seemed somewhat detached, with little evidence of emotional distress at either the situation she was currently in, or of the events that had led up to her arrest for attempted murder. But this in itself was not sufficient to cause us undue concern.

“The person who spoke to you earlier said something about you ‘thinking in 12’s and 24’s’. Could you tell us a bit more about that?” I asked her. On the face of it, this seemed at the very least an unusual, if not irrational, comment to make. She explained that when she was in her 20’s she had trained as a Playboy bunny. This mainly entailed learning how to work in a casino, including operating the blackjack and roulette tables. This, she told me, required an ability to calculate quickly in multiples of 12. She went on to say that she had never actually worked as a bunny girl, as she had not liked the uniform. A rational, plausible and satisfactory explanation.

The two doctors and I had a discussion about the assessment. It was our unanimous conclusion that, whatever may have occurred that night at her home, Stella was not suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital under the Mental Health Act. Although she had gone into inordinate length and detail when questioned, this did not amount to evidence of mental disorder: she did in fact “keep on topic”, and the content of her account was at all times lucid and rational.

I went into the custody office to inform the custody officer that it was our view that Stella was fit to be interviewed. The custody officer gave us a look.

“You’re sure about that, are you?” he said. “Perhaps you’d better have a word with the officer dealing with the case.”

He called the officer in, a detective sergeant.

“We’ve interviewed several of the neighbours,” she told us. “Stella’s known locally as ‘Psychedelic Stella’. One of the neighbours told me she’d known her for 10 years and had ‘never had a sensible conversation with her’. They told us she was ‘not on the planet’. They’ve said she often rides round on her bike wearing ‘green lycra and fairy wings’. You should see the house. It’s in a right state. You’d think they were under siege. You can hardly get to the front door.”

Whether or not Stella did indeed ride her bike dressed in green lycra and fairy wings, it still did not justify detaining her under the Mental Health Act. I saw no reason why this should influence our decision.

“But what if we interview her and decide to bail her?” the detective sergeant asked.

“Then she’ll go home,” I answered. “At the present time both her account and that of her husband seem to corroborate each other. Of course, if there is evidence that she was the perpetrator and he was just covering up for her, then a further psychiatric assessment might be appropriate.”

The custody officer and the detective sergeant did not seem that impressed with our conclusion. But there was still no reason to change our mind.

However, the next day the psychiatrist and I did decide to make further enquiries of our own. We sent Stella an appointment to see us at the CMHT, and I spoke to the medical ward where Stella’s husband was being treated. He had been fortunate. He had missed damaging any internal organs. He had had a psychiatric assessment and had been started on a course of chlordiazepoxide and was already much better mentally. I knew exactly what that meant: it is a treatment for the symptoms of acute alcohol withdrawal; he had had alcoholic hallucinosis again.

Then I had a call from the detective sergeant. They were satisfied the injury had been self inflicted. They had released Stella on bail, but the officer, who was from the local Domestic Violence Unit, now had other concerns. Could I advise whether Stella’s husband, if he was capable of stabbing himself while suffering from the DT’s, might also be capable of harming his wife? Of course, I couldn’t give an opinion, but this made it more imperative to have an opportunity to talk to Stella about the situation.

I tried to make contact with Stella, but no-one seemed to have her mobile number. So I went out to their house. The front verge was crammed with old cars. The front garden contained two old caravans, both crammed full of junk. The rest of the garden was so overgrown, it was difficult to push through to the front door. I could see now what the police had been talking about.

There was no reply when I knocked. I tried to peer through the windows, and could see rooms piled high with rubbish. It seemed difficult to imagine how they might live in this place. It was also difficult to imagine the neat and tidy woman I had interviewed inhabiting this house.

I eventually managed to get Stella’s number, but there was never any reply when I rang it.

A few days later I made contact with the hospital again. Stella’s husband was medically fit for discharge. But did I think he ought to go back to his wife? And was the CMHT going to offer him any follow up?

The CMHT had not had a referral for him. I spoke to the hospital psychiatrist who had assessed him on the ward. Since his initial psychotic presentation was the result of acute alcohol withdrawal in the context of a chronic alcohol problem, the psychiatrist concluded that there was no role for the community mental health team; this was a case for the local alcohol problem service, if he was prepared to accept that he had a problem.

The day before the appointment with us, Stella left a message with our administrative staff. She wouldn’t be keeping the appointment. I rang her number again, and this time she answered. I began to try to explain to her why we would like to see her, but after a few moments she interrupted me.

“If you think I’m going to put myself through another interrogation like the one in the police station, when there’s nothing at all the matter with me, you really must think I’m mad. Goodbye.” She hung up.

And that’s it. A lot of untidy loose ends and unanswered questions. All very unsatisfactory.

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About Me

I am an Approved Mental Health Professional working in a semi-rural area in England. I have practised under 3 Mental Health Acts, since as long ago as 1981, even before the 1983 Mental Health Act. Which makes me pretty ancient now.
This blog is designed to illuminate and explain the functions and dlimemmas of an AMHP within the Mental Health Act. It is intended to be of help to professionals and service users alike. I hope that it is both informative and entertaining.
I am also a freelance trainer, and a part time tutor on an AMHP course. I've appeared at conferences all over England and Wales. If you'd like to book me for your conference or training event just send me an email.